This entry is our account of a study selected by Drug and Alcohol Findings as particularly relevant to improving outcomes from drug or alcohol interventions in the UK. Links to other documents. Hover over for notes. Click to highlight passage referred to. Unfold extra text

Still hard to find reasons for
matching patients to therapies

After finding no overall difference in effectiveness between the two
therapies it tested, the UK Alcohol Treatment Trial (UKATT) has
now also found no differences for different types of patients.1
The results confounded expectations that an approach based on motivational
interviewing would be preferable for the least motivated or most hostile, while
bolstering supportive social networks would be particularly important for
patients lacking these to begin with.

FINDINGS
The trial recruited 742 patients seeking treatment for alcohol problems at seven
specialist treatment services in England and Wales. They were randomly allocated
either to three sessions of motivational enhancement therapy or eight of social
behaviour and network therapy, each spread over eight to 12 weeks. The former
was a familiar elaboration of motivational interviewing, the latter a novel
therapy integrating cognitive-behavioural, community reinforcement and other
elements with the aim of building social networks supportive of positive change
in the patient's drinking. If possible the patient's associates were directly
involved in the process.

Twelve months after therapy started, 85% of surviving participants (12 had
died) were re-interviewed. Across both therapies,
alcohol consumption over the past three months had fallen by 45%.2
There had also been
significant improvements in the severity of alcohol dependence,
alcohol-related problems, and psychological health, and
savings in health and social care costs.3

The
featured study1 tested whether at either the
three-month or the twelve-month follow-ups, certain types of patients had
responded better to one therapy than the other in terms of drinking reductions
(days abstinent, amount consumed when drinking), alcohol dependence, or
alcohol-related problems. It was expected that the non-confrontational style of
motivational interviewing would defuse the hostility of patients prone to react
angrily, and help those relatively devoid of motivation find reasons to curb
their drinking. The network option was expected to particularly help patients
with poor family relationships or few regularly seen associates who were not
also heavy drinkers. Also tested was whether a patient's mental health or
severity of dependence would affect relative responses to the therapies.

Just two of these tests for 'matching' achieved the conventional level of
statistical significance. Both findings were the opposite to what was expected
and (along with near misses) were dismissed as chance outcomes from among the
130 tests.

IN CONTEXT
UKATT derived its hypotheses partly from the US
Project MATCH study, which also found its therapies roughly equivalent and
few and only minor matching effects. Together these methodologically advanced
studies strongly question whether it is worth trying to match alcohol patients
to different outpatient psychosocial therapies. However, alternative analyses
have found statistically and clinically significant matching effects from
Project MATCH and might yet do so from UKATT. Some have been based not on which
therapy was delivered, but on the whether the therapist's interpersonal style
matched that of the patient.4
Another
tailored its analysis to a model of relapse (and its opposite) as often sudden,
wholesale transitions capable of being precipitated in vulnerable individuals by
minor changes in circumstances or psychological state.5

Results like these mean that the possibility of matching patients to
interventions cannot yet be dismissed. Studies might have produced negative
results because they mistakenly assumed it was important to match to the
specific therapy rather than to non-specific, cross-cutting features such as the
interpersonal style of the therapist, or because their analytic model mistakenly
assumed that relapse and recovery are incremental rather than often precipitous.

In another paper
UKATT found just such processes at work as the patients it studied improved.6
Asked what they thought had helped, their answers commonly revealed revelatory
moments which precipitated wholesale transitions in how they saw drinking and
drink and in their determination to change. Others described how an
understanding listener and learning new facts made a difference. The catalysts
for change often preceded treatment entry, and patients saw themselves as
responsible for the changes they had made using the treatments. General influences not specific to either of the treatment approaches were cited by the patients more often than those through which the approach was supposed to distinctively exert its effects, accounts
which might partly explain why these effects were equivalent across the
therapies. Such processes might also explain why in Project MATCH not only were
the therapies equivalent, but it seemed to
make little difference to drinking outcomes whether they were attended or
completed.7

Patients highlighted not just the therapies tested in UKATT, but preceding,
subsequent and parallel interventions, including other treatments and facilities
available at the same clinics and contact with the UKATT team itself. Their
accounts question the implicit assumption that all the savings in health and
social care costs could be attributed to the UKATT therapies, an assumption
which
yielded a ratio of £5 savings for every £1 spent.3

PRACTICE
IMPLICATIONS On the basis of their own work and that of Project MATCH,
the UKATT researchers suggested that therapies such as those tested could be
chosen on grounds other than relative effectiveness, including cost,
availability of therapists, clinical judgement, and patient preference. One
strategy would be to offer the cheaper and more widely available motivational
interviewing first and monitor patients to see if they required further or
different therapy.

For the generality of patients of the kind recruited to treatment trials,
that seems an evidence-based and efficient strategy, but perhaps not one that
should be universally applied. Implemented inflexibly with unsuitable patients,
motivational interviewing can be counter-productive. This
may have happened in Project MATCH.5 Patients who began treatment drinking heavily and lacked confidence in
their ability to resist drink reacted poorly to motivational interviewing. They
drank on far fewer days after cognitive-behavioural therapy. As in
other studies, perhaps these patients floundered without structure,
direction and concrete anti-relapse guidance.8
Sometimes patients
do much better when left to go through treatment in the normal way or given
simple advice, particularly those already committed to a recovery goal and
strategy or who respond counter-productively to the assessment feedback often
featured in motivational interviews.9 Reactions
during the session itself can indicate that this is happening. Sufficiently
sensitive and skilled therapists encouraged to adapt to these signals may avoid
bad reactions, but in other circumstances the risk is that patients who could
have done well from the start will be sent on less positive trajectory.

Thanks to Dr George Christo of the Barnet Drug & Alcohol
Service and to UKATT researchers Nick Heather, Gillian Tober and Jim Orford for
comments on this entry in draft. Commentators bear no responsibility for the
text including the interpretations and any remaining errors.